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This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Purpose of this Notice

We are required by law to maintain the privacy of your protected health information (PHI). This notice applies to all records of the health care and services you received at LVI. This notice will tell you about the ways in which we may use and disclose your PHI. This notice also describes your rights and certain obligations we have regarding the use and disclosure of your PHI.

Who Will Follow this Notice

This notice describes LVI’s privacy practices, as well as the privacy practices of:

any health care professional authorized to enter information into your LVI medical record;

all departments, sections and units of LVI; and

all employees, staff, students and other LVI personnel.

LVI’s Commitment

We are required by law to:

make sure that your PHI is kept private;

give you this notice of our legal duties and privacy practices with respect to your PHI;

follow the terms of this notice as long as it is currently in effect. If we revise this notice, we will follow the terms of the revised notice as long as it is currently in effect;

Each time you visit LVI, a record of your visit is made. Typically, this record contains your diagnoses, examination and test results, treatment, and a plan for care or treatment. This information, often referred to as your health or medical record, serves as a:

basis for planning your care, treatment and any follow up care you may need;

means of communication among the health professionals who contribute to your care;

legal document describing the care you received;

means by which you or a third-party payer can verify that services billed were actually provided;

tool in educating heath professionals;

source of information for medical research;

source of information for public health officials charged with improving the health of the nation;

source of information for facility planning and marketing; and

tool which can be used to assess and improve the care rendered and the results achieved.

Understanding what is in your record and how your health information is used helps you to:

The following categories (listed in bold-face print, below) describe different ways that we use and disclose your PHI. For each category of uses or disclosures we will explain what we mean and give you some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information fall within the categories below.

For Treatment. We are permitted to use and disclose your PHI to doctors, nurses, technicians, medical students or other personnel who are involved in taking care of you at LVI or provide you with medical treatment or services. For example, a doctor treating you may need to know if you have diabetes because diabetes may slow the healing process. Different departments of LVI also may share your PHI in order to coordinate the different services that you need. We also may disclose your PHI to health care providers outside LVI who may be involved in your medical care such as physicians who will provide follow-up care.

For Payment. We are permitted to use and disclose your PHI so that the treatment and services you receive at LVI may be billed to (and payment may be collected from) a third party. For example, we may need to give your health plan information about the surgery you received at LVI so your health plan will pay us or reimburse you for the surgery. We also may tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

For Health Care Operations. We are permitted to use and disclose your PHI for our business operations. These uses and disclosures are necessary to run LVI and to make sure that all of our patients receive quality care. For example, we may use PHI to review our treatment and services and to evaluate the performance of our staff in caring for you. We also may disclose information to faculty physicians, technicians and LVI personnel to conduct training programs. We also may combine certain PHI about several LVI patients as part of a study to determine what additional services LVI should offer, what services are not needed, and whether certain new treatments are effective. We also may remove all information that identifies you from a set of PHI so that others may use that information to study health care and health care delivery without learning who the specific patients are.

To Business Associates for Treatment, Payment and Health Care Operations. We are permitted to disclose your PHI to our business associates in order to carry out treatment, payment or health care operations. For example, we may disclose your PHI to a company we hire to help us obtain payment for the health care services we provide.

Individuals Involved in Your Care or Payment for Your Care. We may release your PHI to a family member other relative or close personal friend who is involved in your medical care if the PHI released is directly relevant to the person’s involvement with your care. We also may release information to someone who helps pay for your care.

Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at LVI.

Treatment Alternatives. We may use and disclose medical information to give you information about treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services. We may use and disclose medical information to tell you about health- related benefits or services that may be of interest to you.

Special SituationsAs Required By Law. We will disclose your PHI when required to do so by federal, state, or local law.

Public Health Activities. We may disclose your PHI for public health activities. For example, public health activities generally include:

reporting reactions to medications or problems with products; or

notifying patients of recalls of products they may be using.

Health Oversight Activities. We may disclose PHI to a health oversight agency for activities authorized by law such as audits, investigations, inspections and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose your PHI in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. We may release PHI if asked to do so by a law enforcement official:

in response to a court order, subpoena, warrant, summons or similar process; or

about criminal conduct we believed occurred on LVI’s premises.

Research. Under certain circumstances, we may use and disclose your PHI for research purposes. For example, a research project may involve comparing the outcomes of surgeries of all patients who received treatment from a particular laser to those who received treatment from another laser. Most research projects, however, are subject to a special approval process. This process requires an evaluation of the proposed research project and its use of PHI, and balances these research needs with our patients’ need for privacy. Before we use or disclose PHI for research, the project will have been approved through this special approval process. However, this special approval process is not required when we allow researchers who are preparing a research project to look at information about patients with specific medical needs, so long as the PHI they review does not leave LVI.

Armed Forces and Foreign Military Personnel. If you are a member of the armed forces, we may release your PHI as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate foreign military authority.

National Security and Intelligence Activities. We may release your PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

When Your Authorization is RequiredUses or disclosures of your PHI for other purposes or activities not listed above will be made only with your written authorization (permission). If you provide us authorization to use or disclose your PHI, you may revoke your authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your PHI for the reasons covered by your written permission. However, we are unable to take back any disclosures we have already made with your permission.

Your RightsYou have the following rights regarding the PHI we maintain about you.

Right to Request Restrictions. You have the right to request a restriction or limitation on the PHI we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the PHI we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. We are not required to agree with your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. LVI will notify you in writing whether we agree or do not agree with your request.

In your request, you must tell us: (1) what information you want to limit; (2) whether you want to limit LVI’s use and/or disclosure of the information; (3) to whom you want the limits to apply (for example, disclosures to your spouse); and (4) your contact address.

Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by telephone at work or that we only contact you by mail at home. Your request must specify how or where you wish to be contacted. We will accommodate all reasonable requests.

Right to Inspect and Receive a Copy. You have the right to inspect and receive a copy of PHI that may be used to make decisions about your care. Usually, this includes medical and billing records. If you request a copy of your PHI, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect or receive a copy in certain very limited circumstances.

Right to Amend. If you believe that PHI we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for LVI.

You must include a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: (1) was not created by us, unless the person or entity that created the information is no longer available to make the amendment; (2) is not part of the PHI kept by or for LVI; (3) is not part of the information that you would be permitted to inspect and copy; or (4) is accurate and complete. LVI will notify you in writing whether we agree or do not agree with your amendment request.

Additionally, if we grant the request, we will make the correction and distribute the correction to those who need it and those you identify that you want to receive the corrected information. If we deny your request for an amendment, we will notify you how you may file a complaint with LVI or the Department of Health and Human Services.

Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures” that have been made by LVI in the past six (6) years. The accounting (or list) of disclosures will include: (1) the date of the disclosure; (2) the name of the entity or person who received the PHI and, if known, the address; (3) a brief description of the PHI disclosed; and (4) a brief statement of the purpose of the disclosure. Your request must state a time period not longer than six (6) years. The first list you request within a twelve (12) month period will be free of charge. For additional lists, we will charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Contact information for these rights. Any requests related to these rights should be directed to:

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice at each LVI location and on LVI’s web site. This notice contains its effective date in the lower right-hand corner. In addition, each time you visit an LVI location you may request a copy of the current notice in effect.

For More Information or to Report a Problem

If you have questions or would like additional information, you may contact LVI’s chief privacy officer at (561) 965-9110.

If you believe your privacy rights have been violated, you can file a complaint with LVI’s chief Privacy Officer at (561) 965-9110 or in writing to:

By submitting this form, I give The LASIK Vision Institute® (LVI) consent to contact me at any phone numbers I provide to LVI, including mobile numbers, via an automatic telephone dialing system in regard to my request for information on LVI services and treatment information.I understand that my consent is not a requirement of purchase from LVI.

*Prices based on prescription: up to -1.00 $299, -1.25 to -2.0 $1099, -2.25 and up as well as all hyperopic and/or greater than -0.50 diopter of astigmatism $1799. Individual results will vary. Candidacy determined by an independent doctor located within or adjacent to the LASIK Vision Institute’s (LVI) facility. All procedures performed by an independent surgeon. Punctal plugs, assurance plans and other technologies available at additional cost. This offer may not be combined with other offers. Other conditions may apply. This offer depicts a model who is not an actual patient of LVI. LASIK is a medical procedure. Talk to your eye doctor and consider both the risks and benefits before having your procedure.

Florida Residents: THE PATIENT AND ANY OTHER PERSON RESPONSIBLE FOR PAYMENT HAVE A RIGHT TO REFUSE TO PAY, CANCEL PAYMENT, OR BE REIMBURSED FOR PAYMENT FOR ANY OTHER SERVICES, EXAMINATION OR TREATMENT WHICH IS PERFORMED AS A RESULT OF AND WITHIN 72 HOURS OF RESPONDING TO THE ADVERTISEMENT FOR THE FREE DISCOUNTED FEE OR REDUCED FEE SERVICE, EXAMINATION OR TREATMENT. Pennsylvania Residents: Please refer to www.lasikvisioninstitute.com for information concerning Pennsylvania’s Credit Services Act.

If you are a resident of Canada and received an email from us, please be advised that this email was sent to you in error. LVI does not have offices or provide services in Canada. We apologize for any inconvenience.